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  1. Most common aetiology of acute appendicitis is idiopathic.
  2. Most common site of gangrenous appendix is TIP.
  3. Most common site of perforation base.
  4. Appendocolith associated with 90% of acute appendicitis.
  5. History: The classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
  6. Migration of pain from the periumbilical area to the RLQ is the most discriminating historical feature. When vomiting occurs, it nearly always follows the onset of pain.
  7. Physical: RLQ tenderness is present in 96% of patients but is a very nonspecific finding.
  8. The most specific physical findings are rebound tenderness, pain on percussion, rigidity, and guarding.
  9. Sign of acute appendicitis: 
Dunphy’s Sign Pain on coughing
Rovsing’s sign Pain in the right lower quadrant during palpation of the left lower quadrant
Obturator sign - Pain on internal rotation of the hip
- Suggestive of pelvic appendix
Iliopsoas sign - Pain on extension of the right hip
- Suggestive of retrocecal appendix
Ponting Sign - Patient point pain to the right iliac fossa.
  1. Lab Studies:
    1. Complete blood count: 80-85% of adults with appendicitis have a WBC count greater than 10,000 and Neutrophilia greater than 75%.
    2. C-reactive protein: C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver in response to bacterial infection.
    3.  Serum levels begin to rise within 6-12 hours of acute tissue inflammation. a normal CRP has a negative predictive value of approximately 100% for the presence of appendicitis.
  2. Imaging Studies:
    1. Computed tomography scan  - diagnostic test of choice.
    2. Ultrasound:  An outer diameter of greater than 6 mm, noncompressibility, lack of peristalsis, or presence of  a periappendiceal fluid collection characterizes an inflamed appendix.
    3. The normal appendix is not visualized in most cases. 
  1. Alvarado’s score (Scoring system for appendicitis is called Alvarado (MANTRELS scoring system).
Symptoms –
  1. Migrating RIF pain – 1                        
  2. Anorexia – 1                                    
  3. Nausea and vomiting - 1
Sign –
  1. RIF tendemed   - 2                                              
  2. Rebound tendemcy – 1                
  3. Fever - 1
Lab –
  1. Leucocytosis -2                                   
  2. Shift to left – 1                                
Total score = 10

Prediction of Appendicitis based on Alvarado score
Scores Prediction
9-10 Appendicitis is certain
7-8 High likelihood of appendicitis
5-6 Equivocal
1-4 Appendicitis can be ruled out
  1. Abdominal x-rays: Visualization of an appendicolith in a patient with symptoms consistent with appendicitis is highly suggestive, but this occurs in < 10% of cases. 
  2. Radionuclide scanning: Whole blood is withdrawn. Neutrophils and macrophages are labeled with technetium 99m albumin and administered intravenously. 
  3. Images of the abdomen and pelvis are obtained serially over 4 hours. Localized uptake of tracer in the RLQ suggests appendiceal inflammation. 
  1. Treatment
    1. Open or laparoscopic appendectomy when no lump formation is there:- (Presentation within 72 hrs)
    2. When lump is form (>72 hrs) – Oshnner sherren regimen is the treatment of choice. Which include
      1. Nill per oral          
      2. IV fluid
      3. Antibiotics for 3-4 days
      4. Elective appendisectomy after 4-6 weeks.
    3. Incision we can use for open appendisectomy –     
      1. Grid iron
      2. Ruther ford Morrison incision.
      3. Lanz incision.   
Abdominal Examination Signs
Sign Description Diagnosis
Aaron sign Pain or pressure in epigastrium persistent firm pressure applied to McBurney's point Acute appendicitis
Bassler sign Sharp pain created by compressing appendix between abdominal wall and iliacus   Chronic appendicitis
Blumberg's sign Transient abdominal wall rebound tenderness Peritoneal inflammation
Carnett's sign Loss of abdominal tenderness when abdominal wall muscles are contracted                   Intra-abdominal source of   abdominal pain
Chandelier sign Extreme lower abdominal and pelvic pain with movement of cervix     Pelvic inflammatory disease
Claybrook sign Accentuation of breath and cardiac sounds through abdominal wall Ruptured abdominal viscus
Courvoisier's sign Palpable gallbladder in presence of painless jaundice Periampullary tumor
Cruveilhier sign Varicose veins at umbilicus (caput medusae) Portal hypertension
Danforth sign Shoulder pain on inspiration Hemoperitoneum
Fothergill's sign Abdominal wall mass that does not cross midline and remains palpable when rectus contracted Rectus muscle hematomas
Mannkopf's sign Increased pulse when painful abdomen palpated Absent if malingering
Ransohoff sign Yellow discoloration of umbilical region Ruptured CBD
Ten Horn sign Pain caused by gentle traction of right testicle Acute appendicitis

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